Psychiatric medications, science, marketing, psychiatry in general, and occasionally clinical psychology. Questioning the role of key opinion leaders and the use of "science" to promote commercial ends rather than the needs of people with mental health concerns.

Thursday, April 05, 2007

...according to a new study in the Archives of General Psychiatry. The authors estimate that about a quarter of depression diagnoses merely reflect people having a difficult time adjusting to a loss. In other words, people often become upset, sometimes exhibiting symptoms of depression (sadness, lack of pleasure in formerly pleasurable activities, excessive guilt, etc.), when they lose a job, a pet, etc.

The current diagnostic system does not weed out these people as not having depression. In fact, the only thing that counts as an "excuse" to have a significant number of depressive symptoms is bereavement (having a loved one die). So if you lose a job, get divorced, lose a pet, have a falling out in a relationship with a friend or family member, etc... the current system says if you have significant symptoms of depression for two weeks or more, then BAM, you're depressed. And we all know that "depression" is predominantly treated with medications. Sure, you might get psychotherapy but the odds of receiving medication are certainly greater than getting psychotherapy. The "epidemic" of depression has been very sweet to those who sell SSRIs.

So, to summarize, tens of thousands of people who have been experiencing difficulties as a result of a loss of some sort have likely been mislabeled as depressed, likely leading to unnecessary treatment. Should real depression be treated? Yep. Should people receive "therapy" of some sort because their boyfriend/girlfriend kicked them to the curb and that's led to a rough month in their life? Hmmm...

Hat Tip: Furious Seasons. BTW, I'd like to write something waaaaaaay more insightful here, but there's only 24 hours in a day, so maybe next week??

Update: Read the comments! Excellent points made by three individuals so far. Feel free to join the conversation...

5 comments:

I am going to have to disagree with you about this. There is a huge difference between diagnosis (clinical ICD-9 or DSM-4R) and symptoms of depression. What about people who miss the diagnosis by 1 symptom, but have 4 really major ones? Clearly the distinctions are arbitrary to say the least.

It is often the symptoms that drive us to treatment even if we don't make criteria. I think its great that studies are recognizing that often people who DON'T make criteria for an actual disorder, need treatment. Maybe not PHARMA but CBT or DBT or other efficacious treatments for symptoms of depression. This is the basis for effectiveness trials, trying to find the best treatment in real life settings. No one is forced to accept any treatment (usually), so it IS up to the individual about self labeling in order to get insurance reimbursement. I would not mind, not paying for therapy at $150 out of pocket, by having my therapist label my reactive depression as major depression.

The reason the diagnoses are so critical, are for replication of studies. If everyone agrees on who is being treated, then its easier for MDs to understand how to prescribe.

I suggest that rather than believing that reaction disorders DON'T require treatment and that people are being misled, perhaps you could consider, that people sometimes DO need help over these humps. Maybe Meds are wrong for this in many cases.. but there should be treatment. People ARE DEPRESSED when they lose their jobs or family members. It doesn't mean they have a disorder.

For example, if your BP goes up because someone keeps pushing your buttons.. does that mean you should not be treated for high blood pressure? Yes, you probably don't need a medication, but yes, you may need to learn how to control your BP in stressful situations using relaxation techniques. This is similar to therapy. I hope more people with reactionary depressions rather than biologically driven depressions do seek appropriate treatment.

I just read the original paper - it was fascinating and good of Philip to pick up on it. It does confirm the common sense notion that sadness resulting from life traumas should not be considered categorically different than the sadness resulting from bereavement.

But it does rely on making a distinction between 'uncomplicated' vs. 'complicated' depressive reactions. Which is fair enough from a scientific point of view, since DSM only considers 'uncomplicated' bereavement to exclude a patient from receiving an diagnosis of Major Depressive Disorder, and it is this 'uncomplicated' exclusionary space that the authors seek to have expanded to include 'uncomplicated' reactions to other losses or stressful events. But in spite of enabling the authors to re-calculate the lifetime prevalence of depression as 11.3% (originally reported as 14.9%), the feeling the paper left me with was of a 'soft' result (necessarily constrained by research protocols) that does not actually pose much of a challenge to the ideology masquerading as science that underpins the conceptualisation and diagnosis of depression.

'Complicated' episodes, whether triggered by bereavement or other forms of loss, were distinguished by the authors from 'uncomplicated' episodes by the existence of at least two of the following: morbid preoccupation with worthlessness, suicidal ideation, marked functional impairment (not being able to work or socialise) or psychomotor retardation, prolonged duration (> 12 weeks) or a suicide attempt. Such 'complications' would enable a diagnosis of depression regardless of any precipitating factors.

I think most of us would agree that someone suffering from at least two of the above might benefit from (and indeed require) some kind of intervention, although those of us who have been damaged and marginalised by the excessive emphasis that mainstream psychiatry places on biogenetic causes would have to seriously question whether psychiatric interventions would be of any use. I doubt that as a result of this paper, mainstream psychiatry will ever stop to consider whether the concepts of 'disease' and 'disorder' are still out of place even in 'complicated' responses to bereavement and other losses, and to begin to think in terms of 'injuries' instead. As the authors point out, false-positive diagnoses can lead to stigmatisation, but even 'true-positive' diagnoses could be reframed in a less stigmatising way.

The latest NICE guidelines for the treatment of depression in primary care for the UK, recommend initially doing nothing (watchful waiting), excercise and then guided self help followed by psychological interventions such as problem solving therapy, brief CBT and counselling.

Antidepressants are not recommeded for the initial treatment of mild depression unless the patient has a history of moderate or severe depression.

Rarely, if ever, has anyone entered psychotherapy with me because they were jilted a week or even a month prior and they were having a difficult time with the experience. Most often people have suffered months if not longer before seeking treatment. Sometimes they seek treatment entirely on their own, but often they do so at the urging of a family member, clergy person or their physician.

What I have seen that disturbs me is that (more than one might expect) physicians too frequently define depression as anything they believe might be pharmacologically responsive to SSRIs or other so-called anti-depressant medications without regard to underlying dynamics. I've seen some pretty serious mistakes when antidepressants and psychoactive medications more broadly are prescribed in this way.

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About Me

I'm an academic with a respectable amount of clinical experience and no drug industry funding. Given my lack of time, don't expect multiple daily updates. Certain things about clinical psychology, the drug industry, psychiatry, and academics drive me nuts, and you'll probably pick up on these pet peeves before long...